PATTAYA, Thailand — Ten years ago, Ukraine wasn’t a relatively large recipient of international aid for health and family planning.

Russia’s invasion of the country last February changed everything. At that time, some 265,000 Ukrainian women were pregnant as medical facilities were destroyed or becoming inaccessible.

Since then, Oleksiy Zhmerenetskyi, a Ukrainian politician who was at the International Conference on Family Planning, said the nation has relied on support from the United Nations Population Fund, the U.N.’s global agency focused on population and maternal and reproductive health. As of January 2023, 661 attacks have impacted medical facilities.

UNFPA, as the agency is commonly known thanks to its original title, the United Nations Fund for Population Activities, has launched mobile medical teams in several regions that provide services, in particular for rural and internally displaced women, established a hotline for psychosocial services and distributed dignity kits, which include hygiene and other items needed in a crisis and maternity kits to individuals and hospitals.

“International organizations support the functioning of [the] health care sector, particularly reproductive health care, for which we are infinitely grateful,” said Zhmerenetskyi.

The United States has historically ping-ponged between being one of the world’s largest donors to UNFPA and pulling its funding altogether, even though the agency is based in New York City.

What happens this year will be telling. 2023 marks the start of a new split Congress and the lead-up to next year’s presidential election — both factors in funding policy related to the UNFPA, which relies on voluntary contributions.

The agency’s priorities include preventing gender-based violence, reducing teen pregnancy, improving the health of pregnant women, providing birth and dignity kits to women affected by disasters and spearheading data collection used for development efforts.

The president determines if the U.S. will fund UNFPA, meaning support for the agency and its program goals can vary depending on what party is in the White House and how they interpret an annual appropriations rider. Under President Joe Biden, Congress has appropriated $32.5 million for UNFPA in fiscal years 2021-23. Democrats have generally supported consistent funding for the agency.

But some Republicans have hesitations. The agency’s main U.S. opposition comes from those who argue that the agency supports “coercive abortion” in China.

Since the 1980s, Republicans have criticized UNFPA’s program in China. Their concerns led to the 1985 Kemp-Kasten amendment, an annual rider that prohibits using federal funds for programs that support “coercive abortion or involuntary sterilization.”

Since 1994, the annual State-Foreign Operations spending bill has typically included additional restrictions targeting UNFPA programming in China. The U.S. largely withheld funding to the population agency under the Reagan, Trump and both Bush administrations.

UNFPA officials have said the lack of clarity on the agency’s funding makes it especially difficult to maintain or plan for future programs, especially in light of population increases, climate-related disasters and humanitarian crises.

“We know that member states change, you know, there’s politics that change priorities,” said Giulia Vallese, deputy regional director for Eastern Europe and Central Asia at UNFPA, adding that the agency advocates for flexible funding. “Especially in the case of Ukraine, things evolve so rapidly that you need to be able to adjust. And some member states are more flexible and they agree to pool resources to give us, and others are much more strict.”

Humanitarian crises

Predicting when natural and human-caused crises could strike is difficult, but experts expect the number of climate-related crises to continue rising.

Tomoko Kurokawa, regional humanitarian adviser for UNFPA’s Asia-Pacific Regional Office, said Bangladesh and Pakistan in 2022 experienced some of the worst monsoon floods in decades.

“What we’re seeing in the news and what is being reported really does not capture the scope of what is actually happening on the ground,” said Kurokawa, who visited some of the hardest-hit provinces and displacement camps.

One or two families would cram into a tent with no privacy. The 200-tent displacement camp had only two latrines not segregated by gender. Women here, she said, told her they are unable to manage their menstrual health.

“They don’t want to go to these latrines that have no privacy, and there’s no access to clean water. So it’s really just the basics, even hygiene and sanitation needs, that are not being met because of these climate-induced disasters,” Kurokawa said.

Planning ahead is vital when funds allow. She said UNFPA pre-positions items like menstrual supplies and tents to be used for maternal delivery, as well as reproductive health kits that health facilities can use to maintain services related to sexually transmitted infections or family planning.

“In the event of a desk disaster, they can be immediately distributed to be on the ground in the field within 48 to 72 hours,” she said.

Many countries often lack current data, which is essential in a developing crisis. In February 2022, at the start of the conflict in Ukraine, the country’s most recent census data was from 2001 and slated to be updated in 2023.

UNFPA assembled updated common population data and projections and made them available for relief efforts in early March 2022.

Data sets help humanitarian groups plan where to send different types of medical supplies, kits and services in impacted areas, including refugee displacement sites.

Continued displacement — both internally and to neighboring nations — keeps Mustafa Elkanzi, UNFPA’s senior emergency coordinator and deputy representative in Ukraine, up at night.

“We don’t want people to move, especially in the newly retaken areas,” Elkanzi said. “It is better to keep people where they are and keep them safe at home. But if they move, they move where? That’s the question with all these missiles hitting everywhere.”

Political ping-pong

Advancing global maternal health outcomes is a common objective, though Democrats and Republicans differ on the United States’ role in how this is carried out.

“The United States is proud to be the world’s largest bilateral donor of family planning systems, and we continue to do that, no matter what party is in power, as an American commitment,” Atul Gawande, assistant administrator of the U.S. Agency for International Development, said at the International Conference for Family Planning in November. “We remain steadfastly committed in the Biden administration to protecting and advancing sexual and reproductive health and rights for all.”

USAID partners with UNFPA on humanitarian efforts, providing more than $12.4 million to the agency’s Ukraine response in fiscal 2022.

But Gawande acknowledged that differing opinions on topics like abortion have been roadblocks — including delaying his own confirmation.

“I understand how difficult and contentious these issues remain,” Gawande said.

Funding changes can complicate long-term planning when donor countries have different priorities or resources.

The U.S. has prioritized funding census and data collection efforts in other countries, but if the U.S pulls out in the middle of a project, those efforts halt.

Efforts in Afghanistan to complete a social and demographic survey were cut short when the Trump administration pulled funding for the agency in 2017. UNFPA had received two initial sets of funding, but not the third allocation of about $5 million needed to finish the project.

Last Congress, lawmakers floated two avenues for the future of the UNFPA debate, though neither bill was taken up for a hearing or markup by the House Foreign Affairs Committee.

Rep. Chrissy Houlahan, D-Pa., introduced legislation that would authorize UNFPA funding for five years. She intends to reintroduce it this year. Rep. Chip Roy, R-Texas, previously introduced legislation that would ban federal funding from supporting the UNFPA.

The U.S. is not alone in its contribution fluctuations, but funding changes from other countries are mainly limited to widespread budget sequestration rather than a focus on the agency itself.

In 2021, the United Kingdom scaled back funding for UNFPA supplies by 85 percent — a surprise from a country that had otherwise been a “bedrock donor,” said UNFPA’s executive director, Natalia Kanem.

Lindsay Northover, a Liberal Democrat member of the U.K. House of Lords, said that at the time the U.K. was the largest contributor, causing a big impact in terms of supplies.

“A sudden change like that is absolutely unacceptable. We’re a wealthy country,” Northover said. “Now, cross-party working has brought that back up again to some degree, but not matching where it was before. And so that is the challenge that we face at the moment.”

The Russia-Ukraine war has also increased currency volatility, especially in European countries, which Kanem said has made it difficult to budget the value of the agency’s coffers.

“We’re all worried about the knock-on effects of the very strong dollar,” Kanem said. “It’s a very volatile situation, and politics is a big part of it.”

Vallese said other U.N. member states in the past have tried to step up their contributions to compensate for global policy fluctuations, as have private donors.

“Of course, it’s never the same, because we know the U.S. plays a big role,” said Vallese. “But it’s also preparedness and contingency planning to the extent possible, but definitely it’s an issue.”